Prevalence and determinants of anaemia among women of reproductive age in Aspirational Districts of India: an analysis of NFHS 4 and NFHS 5 data

Background Over one-third of women worldwide suffer from anaemia. The prevalence of anaemia is particularly pronounced among women of reproductive age (WRA) in developing countries, such as India. No prior study has ever exclusively studied the prevalence of anaemia across the Aspirational Districts of India. Therefore, the purpose of this study was to examine the prevalence of anaemia across Aspirational Districts of India and to identify the determinants of anaemia among WRA in these districts. Methods From the National Family Health Survey (NFHS)-4 (2015-16) and NFHS-5 (2019-21), data on 114,444 and 108,782 women aged 15–49 from Aspirational Districts were analyzed in our study, respectively. Bivariate statistics and multivariable binary logistic regression were used to identify the determinants of anaemia. Results The national prevalence of anaemia among WRA has increased from 53% in NFHS-4 to 57% in NFHS-5 whereas anaemia among WRA in Aspirational Districts has increased from 58.7% in NFHS-4 to 61.1% in NFHS-5. Between 2015 and 2021, over 60% of Aspirational Districts experienced an increase in the prevalence of anaemia and one-fourth, specifically 29 out of 112, observed a rise by at least 10 percentage points (pp). Notably, there are significant variations in anaemia prevalence among districts, with Simdega and Udalgiri having the highest anaemia prevalence in NFHS-4 and NFHS-5 at 78.2% and 81.5%, respectively. During this period, Barpeta followed by Udalgiri of Assam have witnessed the maximum increase with 29.4% and 26.7% respectively. Moreover, pooled regression results show women with three to four children [AOR: 1.13, 95% CI: 1.08–1.17], women who breastfeed [AOR: 1.17, 95% CI: 1.13–1.20], Scheduled Tribe women [AOR: 1.39, 95% CI: 1.35–1.44], poorest women [AOR: 1.27, 95% CI: 1.22–1.33] and women those who consume fish occasionally [AOR: 1.14, 95% CI: 1.12–1.17] were more likely to be anaemic. Conclusion The significant increase in anaemia among WRA in Aspirational Districts of India is a matter of concern. Given the rise in anaemia among WRA, determinants-based and district-specific measures must be designed and implemented to reduce the prevalence of anaemia among Aspirational Districts of India. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-024-17789-3.


Background
Anaemia is a condition where the count and size of red blood cells, or the concentration of hemoglobin, drop below a defined threshold [1].According to World Health Organization (WHO), pregnant women are considered anaemic if their hemoglobin concentration is less than 11.0 g/dl, while non-pregnant women are considered anaemic if their hemoglobin concentration is below 12.0 g/dl [2].Anaemia has three main causes: nutritional deficiencies, infectious diseases, and genetic disorders related to hemoglobin [3,4].Iron-deficiency anaemia stands out as the most prevalent type in developing nations [5,6].A global analysis indicates that anaemia affects 27% of the world's population, with iron deficiency being the primary cause [7,8].Inadequate intake of essential nutrients such as iron, vitamin B12, and folic acid, coupled with excessive consumption of tea, coffee, and certain spices, can lead to nutritional deficiencies that often result in anaemia [3,9,10].Similarly, genetic disorders, such as vitamin A, riboflavin, and folate deficiencies, sickle cell disease, glucose-6-phosphate dehydrogenase deficiency, as well as conditions like malaria, human immunodeficiency viruses (HIV), and tuberculosis, significantly contribute to the development of anaemia [3,11].It is a significant public health concern impacting approximately half a billion women aged 15-49 years [12].In 2019, WHO estimates 30% (539 million) of non-pregnant women and 37% (32 million) of pregnant women aged 15-49 years were affected by anaemia [12].
Anaemia holds crucial importance in the context of achieving Sustainable Development Goals (SDGs), particularly SDG-2 (Zero Hunger) and SDG-3 (Good Health and well-being) [23,24].Around half a billion WRA are anemic globally, with anaemia being higher in low and middle-income countries (LMICs) like India [14,25].The most recent National Family Health Survey (NFHS) reveals a significant burden of anaemia, impacting 57% of WRA in India, while in the Aspirational Districts, the prevalence of anaemia among WRA is even higher at 61% [26].Earlier research conducted in India identified that low socioeconomic status, limited educational attainment, increased childbearing, residing in rural areas, women belongs to lower social groups, and inadequate dietary intake were associated with anaemia among WRA [22,[27][28][29][30][31].Furthermore, a study on urban India found that anaemia was associated with low serum ferritin levels indicating iron deficiency [32,33].It is noteworthy that these studies are primarily focused on broader population trends within the country.The significance of studying anaemia in Aspirational Districts is underscored by its correlation with low economic status, a prevalent characteristic among women in Aspirational Districts [34][35][36].
The "Aspirational Districts" program was launched by the government of India in 2018.These districts were characterized by poor development indicators, high rates of poverty, and limited access to healthcare facilities, making them vulnerable to health and nutritionrelated issues like anaemia [34,37].These districts were selected based on their poor performance across various development indicators, including health, education, nutrition, and basic infrastructure [37,38].Earlier research conducted in the Aspirational Districts predominantly focused on socioeconomic status, maternal and child health and the effectiveness of education, with no research specifically addressing anaemia which is a critical health issue prevalent among WRA [39][40][41][42][43].By examining the prevalence of anaemia in Aspirational Districts, the research aims to inform targeted interventions aimed at reducing anaemia rates and improving the wellbeing of WRA in these districts.
Our study has the following objectives.First, our study measures the prevalence of anaemia among WRA in Aspirational Districts in NFHS-4 and NFHS-5.Second, the study aims to examine the factors associated with anaemia among WRA in Aspirational Districts.The study results may aid policymakers, public health researchers, and health professionals in better comprehending the shifting nature of anaemia across Aspirational Districts.family planning, maternal and infant nutrition, maternal and infant empowerment and more.Ministry of Health and Family Welfare, Government of India (MOHFW) conducted the study managed by the International Institute of Population Sciences (IIPS), Mumbai.Using a twostage stratified random sampling method in each phase, NFHS-4 (2015-16) conducted interviews with 699,686 women aged 15-49 years across 572,000 households.In comparison, NFHS-5 interviewed 724,115 women aged 15-49 years from a total of 636,669 households with a response rate of 97% in both rounds [26,44].

Study sample
The "Aspirational Districts" program was launched by the government of India in 2018 [36].The program was a part of India's broader development agenda, which aims to promote inclusive and sustainable development across the country [37,45].These districts were selected based on their poor performance across various development indicators, including health, education, nutrition, and basic infrastructure [45].Health was an important component of this program, accounting for almost 30%, with a focus on indicators like anaemia among women.A total of 112 districts from 27 states were identified as "Aspirational Districts".Among these districts, there were 19 from Jharkhand, 13 from Bihar, ten each from Chhattisgarh and Odisha, eight each in Uttar Pradesh and Madhya Pradesh, seven in Assam.Rajasthan and Maharashtra have five and four districts, respectively, while Andhra Pradesh and Telangana each have three.Additionally, Uttarakhand, Tamil Nadu, Punjab, Jammu and Kashmir, Gujarat, and Karnataka have two districts.On the other hand, Arunachal Pradesh, Haryana, Himachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura each contribute one district to the program [34,38,45,46].
For our study, we opted to include Visakhapatnam and Vizianagaram districts from Andhra Pradesh, even though Alluri Sitharamaraju and Parvathipuram Manyam districts are part of the Aspirational Districts program.This decision was based on the fact that the NFHS-4 and NFHS-5 surveys, conducted in 2015-16 and 2019-21, respectively, covered Visakhapatnam and Vizianagaram as survey districts.It's worth noting that Alluri Sitharamaraju and Parvathipuram Manyam districts were formed in 2022 from Visakhapatnam and Vizianagaram, respectively.This choice was made to maintain consistency with the time frame of the survey data.The detailed list of Aspirational Districts used for this study is given in Supplementary Table 2.
For the present study, data was extracted from two consecutive rounds of NFHS.A total of 114,444 and 108,782 women aged between 15 and 49 years were chosen from NFHS-4 and NFHS-5, respectively.The detailed sample selection process is given in Fig. 1.

Hemoglobin testing
Health investigator took blood samples for anaemia testing from all women aged 15-49 who voluntarily consented to the testing.A drop of blood from a finger prick was used to collect blood samples in a microcuvette.In addition, on-site hemoglobin was tested using a batteryoperated portable HemoCue Hb 201 + analyzer [26].

Conceptual framework
The framework illustrates various anaemia related variables which might affect the magnitude of anaemia in the Aspirational Districts of India.Three main domains of variables (biodemographic and socioeconomic, behavioural and health related variables) were selected for the study, which are described later in this section.The analysis for this study is based on this conceptual framework adapted from the existing literature on anaemia [47][48][49][50][51][52][53].The conceptual framework is shown in Fig. 2.

Dependent variable
The variable representing the level of anaemia in both the NFHS-4 and NFHS-5 datasets is an ordinal variable having four categories: no anaemia, mild anaemia, moderate anaemia, and severe anaemia.The level of anaemia is designated as mild if hemoglobin level is between 11.0 g/ dl to 11.9 g/dl for non-pregnant women and 10.0 g/dl to 10.9 g/dl for pregnant women, moderate if hemoglobin level is between 8.0 g/dl to 10.9 g/dl for non-pregnant women and 7.0 g/dl to 9.9 g/dl for pregnant women and severe if hemoglobin level is within < 8.0 g/dl for nonpregnant women and < 7.0 g/dl for pregnant women [26].The dependent variable in this study was whether reproductive women were anaemic or not anaemic.The dependent variable is coded as a dichotomous variable, with '1' indicating "anaemic" for women with mild, moderate, or severe anaemic conditions, and '0' indicating "not anaemic" for women having no anaemia.

Independent variables
Based on prior research on anaemia, the independent variables were chosen for the study [32,33,47,[54][55][56][57].These variables included age, marital status, parity, breastfeeding status, pregnancy status, level of education, social groups, religion, household wealth, type of residence, mass media exposure, frequency of eating eggs, frequency of eating fish, frequency of eating chicken, current contraceptive use, alcohol consumption, body mass index (BMI), currently having diabetes and currently amenorrhea.These variables were divided into three domains: (a) biodemographic and socioeconomic; (b) behavioural and (c) health related variables.Table 1 Fig. 2 Conceptual framework showing determinants of anaemia

Household wealth
The wealth index is a composite index of household amenities and assets; it indicates the socioeconomic condition; every household is given a score based on the number of consumer goods they own.A total of 33 assets and housing characteristics were taken into consideration to prepare a factor score using Principal Component Analysis.Thereafter this factor score was divided into five equal categories, − 'poorest' (coded as '1'); 'poorer' (coded as '2'); 'middle' (coded as '3'); 'richer' (coded as '4'); 'richest' (coded as '5') each with 20% of the population.Type of place of residence Place of residence had two categories: 'urban' (coded as '0'), 'rural' (coded as '1').

Behavioral variables
Mass media exposure Three questions were asked to women in NFHS-4 and NFHS-5.They are i) how often they read newspaper/magazines, ii) how often they watch television, and iii) how often they listen to radio.The responses are 'almost every day' , 'at least once a week' , 'less than once a week' and 'not at all' .Based on these responses a composite index was computed and divided into four categories: 'no' (coded as '0') if the respondent is not exposed to any mass media, 'low' (coded as '1') if a respondent is exposed to any one type of mass media, 'medium' (coded as '2') if the respondent is exposed to any two types of mass media, 'high' (coded as '3') if the respondent is exposed to all three types of mass media.

Current contraceptive use
NFHS classified the contraceptive into 20 categories, all these categories.All these responses was recoded into two categories for this study: 'no or traditional' contraceptive use (coded as '0'), if a woman did not use anything or used periodic abstinence, withdrawal, other traditional method, or prolonged abstinence to delay or avoid getting pregnant; and 'modern' contraceptive use (coded as '1') if a woman used pill, intrauterine device, injections, diaphragm, male condom, female sterilization, male sterilization, implants/norplant, lactational amenorrhea method, female condom, foam or jelly, emergency contraception, other modern method, standard days method, specific method 1, or specific method 2.

Health related variables Body Mass Index
It is defined as the ratio between the weight of a women in kilogram divided by the squared height in meter.Body mass index was divided into four categories according to WHO cutoff; underweight (< 18.5 kg/m 2 ) coded as '1' , normal (18.5 kg/m 2 -24.99 kg/m 2 ) coded as '2' , overweight (25 kg/m 2 -32 kg/m 2 ) coded as '3' and obese (> 32 kg/m 2 ) coded as '4' [58].
provides a detailed list of independent variables used in this study.

Statistical analysis
The study analyzed the prevalence of anaemia among WRA in Aspirational Districts of India by their background characteristics.We additionally evaluated the temporal change in the prevalence of anaemia for each Aspirational District during the study period.This analysis allowed us to identify variations in anaemia prevalence at a more detailed level.The chi-square test was used to analyze the statistical significance of the association between outcome variable and each independent variable [59].Furthermore, multivariable binary logistic regression was used to examine the association between dependent variable and independent variables [60].The data from NFHS-4 and NFHS-5 were pooled for this analysis.By combining these datasets, we were also able to examine the independent effect of the survey year on the likelihood of anaemia [61].Three models were constructed and a block-wise forward selection method was used to eliminate any variables that were statistically insignificant (p > 0.05).Variables were introduced in blocks, and only those with a p < 0.05 were included in the subsequent models.Model 1 included biodemographic and socioeconomic variables, including age, marital status, parity, breastfeeding status, pregnancy status, level of education, social groups, religion, household wealth, and type of place of residence.Model 2 included statistically significant variables from model 1 and behavioral variables including mass media exposure, frequency of eating egg, frequency of eating fish, frequency of eating chicken, current contraceptive use, alcohol consumption, and model 3 contained significant variables from model 2 and health-related variables including BMI, currently having diabetes, currently amenorrheic and year.Adjusted odds ratios (AOR), p-values (< 0.05), and 95% confidence intervals (CIs) were used to show the results of logistic regression models.In addition, variance inflation factors (VIFs) were calculated to determine the degree of multicollinearity [62] (see additional Table 1).The mean VIF value was under the threshold value of five in all the models, which indicated that multicollinearity was not a problem for the models.
Furthermore, we applied Nagelkerke R square and Hosmer & Lemeshow tests to assess the goodness-of-fit of the models.Firstly, we conducted Nagelkerke R square, this helped us see how likely our model was to produce the observed data, and a lower log likelihood meant a better fit [63].Additionally, we conducted the Hosmer-Lemeshow goodness-of-fit test.The Hosmer-Lemeshow test helped us assess how well our model's predictions matched the actual outcomes, and if the result were not significant, it suggested a good fit [64].In addition, we examined Akaike information criterion (AIC), Bayesian information criterion (BIC) and log likelihood.Higher log likelihood, and low AIC and BIC values indicated a better fit.[65].
Stata 16 was used for statistical analysis, and the 'Svyset' command was utilized to adjust for the complex survey design (sampling weights) of the NFHS-4 and NFHS-5 [66].

Respondents' characteristics
Table 2 presents the socio-demographic profile of WRA of Aspirational Districts.In both rounds of the NFHS, it was found that more than one-third of women were aged between 20 and 29, and around three-fourths of women were currently married.A minuscule percentage of women were pregnant and over 10% of women had five or more children.Furthermore, more than fourfifths women were identified as Hindu, and nearly half of the women belonged to OBC.Over one-third of women had not received any formal education and belonged to the lowest socioeconomic class.Contraceptive practices revealed that over 60% of women either used traditional methods or did not use any family planning method.In addition, across both rounds, over one-third of women reported that they occasionally ate egg, fish, and chicken.A small proportion of women in both rounds suffered from diabetes and amenorrhea.

Prevalence of anaemia among WRA by background characteristics
In NFHS-4, approximately 59% of WRA in Aspirational Districts were reported as anaemic.However, this percentage increased to 61% in NFHS-5.Table 3 presents the prevalence of anaemia among WRA from 2015 to 2021 in Aspirational Districts of India by background characteristics.In both rounds of the NFHS, the rates of anaemia remained nearly constant across all age groups, hovering around 60%. Furthermore, women with three to four children consistently exhibited the highest anaemia prevalence.However, the rate of anaemia increase was more pronounced among women with no children.Additionally, in both rounds of survey, the prevalence of anaemia was higher among women with no education, whereas those with higher education consistently had the lowest prevalence.In terms of household wealth, it was found that anaemia was higher among poorest category of women and lowest among the richest category.
The prevalence of anaemia also varied among different social groups.Specifically, the rates were relatively higher among ST women during both surveys.However, the rate of increase in anaemia prevalence was notable among women from other social groups, with a 6 percentage point (pp) rise.Furthermore, during both  rounds, the prevalence of anaemia was also higher among women those who occasionally ate eggs, fish and chicken.Although, the rate of increase in anaemia prevalence was more pronounced among WRA those who never consumed any of abovementioned food, with a nearly 4 pp rise.Women utilizing modern contraceptive methods exhibited a lower prevalence of anaemia compared to those using traditional or no contraceptive methods.Additionally, in NFHS-5, over 70% of WRA who consumed alcohol were found to be anaemic.Across both survey rounds, underweight women consistently exhibited the highest prevalence of anaemia, whereas overweight women consistently had the lowest prevalence.Notably, the increase in anaemia prevalence was more notable among overweight women, showing an increase of over 4 pp between the two survey rounds.Furthermore, women with diabetes were less likely to experience anaemia.However, in the case of amenorrhea, the prevalence of anaemia was highest among women with amenorrhea and lowest among those without amenorrhea in both rounds of NFHS.

Distribution of anaemia among WRA in Aspirational Districts of India during NFHS-4 and NFHS-5
Figure 3 illustrates that in both rounds of the NFHS, the prevalence of anaemia among WRA in Aspirational Districts exceeded that of non-aspirational districts and the national average.Nationally, 53.2% and 57% of WRA in India were anemic in NFHS-4 and NFHS-5, respectively.In contrast, the prevalence in Aspirational Districts was 58.7% and 61.1% in NFHS-4 and NFHS-5, respectively.

Discussion
This study examined the prevalence of anaemia among WRA in Aspirational Districts of India between 2015 and 2021.During NFHS-4 and NFHS-5, the prevalence of anaemia among WRA within Aspirational Districts was higher than the national prevalence of anaemia.Within the Aspirational Districts, 72 districts experienced an increase, while 40 districts witnessed a decline in anaemia among WRA.Anaemia prevalence varied across Aspirational Districts, a majority of Aspirational Districts from Chhattisgarh and Bihar experienced a major rise in anaemia.While Aspirational Districts from Jharkhand and Uttar Pradesh observed a considerable decline in anaemia among WRA from 2015 to 2021.In terms of specific districts, Chandel of Manipur consistently faced the highest anaemia prevalence in both rounds of NFHS.In contrast, Simdega of Jharkhand and Udalguri of Assam witnessed the lowest anaemia prevalence in NFHS-4 and NFHS-5, respectively.During both rounds of survey, Barpeta and Udalgiri of Assam witnessed the highest increase in anaemia while, Chitrakoot of Uttar Pradesh and Kalahandi of Odisha witnessed highest decline in anaemia respectively.
After controlling for a number of factors, the regression results revealed that, women education, their wealth status, breastfeeding status, mass media exposure, social   groups, underweight women, frequency of eating fish, and amenorrhea were associated with anaemia among WRA of Aspirational Districts of India.This study found that women with higher education were less prone to be anaemic, this is supported by previous studies which identified women with higher education levels are less likely to develop anaemia than those with lower education levels [32,47,53,67].A possible reason could be, education provides knowledge and awareness about nutrition, health, and hygiene, which are essential for preventing anaemia [61,68].In addition, women with higher education levels are also more likely to have better access to healthcare, including prenatal care during pregnancy, which might help in managing anaemia [47].
Our study also revealed that poorest women had higher odds of anaemia compared to richest women.Poorest women face insufficient access to food resources, struggled to afford well-balanced meals, often reduced meal sizes, and occasionally skipped meals, all of which could contribute to anaemia [69][70][71].Furthermore, knowledge of different vitamin and mineral-containing foods is generally limited among the lower wealth status women, which could be another factor contributing to anaemia [69,72].Furthermore, women with lower wealth status generally have limited access to healthcare services making diagnosing and treating anaemia more difficult [73,74].On the contrary, women belonging from the highest and richest households are associated with better nutritional status and were less vulnerable to get anaemia [69,75,76].Additionally, lower wealth levels also lack resources for basic hygiene, such as clean water and sanitation facilities, which might increase the risk of infectious diseases that associate with anaemia [61].
Similar to many previous studies, this study also identified a positive association between anaemia and breastfeeding [25,53,61].A study conducted in Pakistan revealed that inadequate consumption of enough ironrich foods in their diet might cause insufficient milk supply, resulting in a shorter breastfeeding and the return of menstruation [25].This, in turn, can contribute to iron deficiency and the beginning of anaemia [25,77].Though the relationship between breastfeeding and anaemia among WRA is little complex, which requires additional research for the better understanding.
The findings of the study indicated that increased mass media exposure was associated with a lower prevalence of anaemia.One possible explanation might be women with greater mass media exposure have greater access to information regarding the significance of nutrition and healthy behavior, such as consuming iron-rich foods or taking iron supplements [78].Additionally, women with a significant exposure to mass media may be more likely to know about healthcare services, such as regular check-ups such as blood tests, which can aid in the early identification and treatment of anemia [79][80][81].
Our study also revealed that ST women were more likely to be anaemic than women from other social groups.Some previous studies have also revealed that anaemia is a significant health problem among tribal women in India [32,48,82,83].The higher anaemia prevalence in tribal women may have been a result of limited access to nutritious foods, including iron, folate, and vitamin B12 [84].Moreover, dietary habits, poor sanitation practices, cultural norms like early marriage, insufficient maternal care, and taboos may collectively contribute to the prevalence of anemia among women of reproductive age in tribal communities [83,85].
The relationship between fish consumption and anaemia is a bit complex.Some previous studies have indicated that anaemia tends to increase with fish consumption, a finding consistent with our own study [86].However, there are some studies where it is found that anaemia does not increase with the consumption of fish [87,88].A possible explanation for these results may be that non-vegetarians have a higher animal protein intake, which can increase the body's need for iron [89].However, the underlying reasons for this complex relationship remain somewhat unclear and warrant further investigation.
Additionally, our study uncovered an association between underweight women and the prevalence of anemia.Previous studies have similarly shown that underweight women are associated with an elevated risk of anaemia [47,67,90,91].The potential cause for this could be insufficient intake of essential nutrients, such as iron and folate, and an inadequate diet, which are the predominant immediate causes of anaemia among WRA [67,91].Underweight individuals may also be more susceptible to chronic illnesses and inflammation which can interfere with the body's inability to produce red blood cells, leading to anaemia [92,93].
This study also identified an association between increased prevalence of anaemia and women who had experienced amenorrhea, consistent with earlier studies conducted in India [61].This could be attributed to inadequate iron levels in the body, which typically result from improper and insufficient diet [25].When the diet is inadequate, the body cannot produce an adequate amount of iron, leading to amenorrhea and subsequently resulting in anaemia among WRA [25,77].
The Indian government has implemented a series of programs and policies aimed at preventing and eliminating anaemia among women.This began with the National Nutritional Anaemia Control Program (NNACP) in 1970, followed by the National Nutritional Policy in 1993.Additionally, Iron and Folic Acid Supplementation (WIFS) program, initiated in 2012, focused on providing iron and folic acid supplements to school-going and adolescent girls, aiming to prevent anaemia [94][95][96].The National Iron + Initiative, launched in 2013, aimed to improve the quality and accessibility of iron and folic acid supplements in the public health system [97].The Anaemia Mukt Bharat program (2018) aimed to increase awareness about anaemia, provide iron and folic acid supplements to vulnerable groups, and strengthen the health system for effective anaemia prevention and treatment [98].Moreover, there are some states like Chhattisgarh and Uttar Pradesh where initiatives were adopted in order to eradicate NCDs including anaemia from Aspirational Districts [99,100].However, in addition to these initiatives, it is essential for more states to bring effective measures in Aspirational Districts to improve the condition of anaemia among WRA.
The major strength of this study is that this is the first national-level study to assess the prevalence of anaemia among WRA in Aspirational Districts using NFHS-4 and NFHS-5 datasets.Additionally, the study concentrated on assessing district-level anaemia prevalence and its temporal changes, aiming to inform the development of district-specific interventions to mitigate anaemia among women of reproductive age (WRA).Furthermore, the study studied the determinants of anaemia among WRA, which might help policy makers adopt specific measures to reduce anaemia among WRA in Aspirational Districts.One of the key limitations of this research arises from its cross-sectional survey design, which restricts causal inferences and instead permits only the establishment of associations between dependent and independent variables.An additional limitation is the exclusion of some key variables, such as folate, vitamin B12, vitamin A intake, access to healthcare services, and cultural beliefs and practices, which could influence anaemia prevalence but were not included due to their unavailability in the dataset.Furthermore, the reason of anaemia within WRA in Aspirational Districts is unknown because most Aspirational Districts research focuses on socioeconomic status, mother and child health, and education efficacy etc.Therefore, future research should incorporate more variables to provide a more comprehensive and accurate picture of the prevalence of anaemia among WRA of Aspirational Districts of India.

Conclusion
Anaemia among WRA in Aspirational Districts was found higher than the national prevalence.Our study revealed that women with secondary education, ST women, poorest women, women who consume fish occasionally, underweight women and those with amenorrhea were associated with anaemia among WRA.The Government of India has taken several steps to reduce the prevalence of anaemia among women at national level, however there is a need to adopt some specific measures for Aspirational Districts too.More concerted efforts are needed to eradicate anaemia from Aspirational Districts.Focus towards healthy food consumption, better economic condition and higher education for women must be given importance.At the same time knowledge and awareness towards anaemia must be promoted among women.Implementing targeted public health programs in Aspirational Districts with higher prevalence of anaemia may reduce the issue at the grass-root level.

Fig. 1
Fig. 1 Process of sample selection for the study from NFHS-4 and NFHS-5

Table 3
Prevalence of anaemia among WRA (15-49 years) by background characteristics in Aspirational Districts of India, NFHS-4 and NFHS-5.Aspirational Districts experiencing a reduction by ten or more pp (see additional Table2).Aspirational Districts from Chhattisgarh witnessed a significant increase in anaemia, with 9 out of 10 districts experiencing a rise.Similarly, Bihar faced notable concerns, as 10 out of its 13 Aspirational Districts reported an increase in anaemia.Additionally, 6 out of 10 Aspirational Districts of Odisha observed an increase in anaemia.In contrast, states like Jharkhand, where 12 out of 19 Aspirational Districts experienced a decline in anaemia.Similarly, 7 out of 8 Aspirational Districts of Uttar Pradesh witnessed a decline in anaemia among WRA from 2015 to 2021 (see additional Table2).Additional Table 2 also shows, during both rounds, Chandel district of Manipur consistently experienced the highest anaemia among all Aspirational Districts, with 78% and 81%, respectively.On the other side, Simdega of Jharkhand in NFHS-4 and Udalguri of Assam in NFHS-5, witnessed the lowest anaemia prevalence, with at 23% and 27%, respectively.In addition, during both rounds, Barpeta followed by Udalgiri of Assam witnessed the maximum increase in anaemia with 29.4% pp and 26.7%